Cage’s Rehab: Strength

With Cage now somewhat comfortable and showing improvement with rehab, we could really start things moving. In doing that, I had to anticipate that Cage WOULD get better. That meant putting some things in place so that WHEN he was walking his body would be at its best.

The first thing I added to his regiment was a Chinese herbal compound called Double PII. This is a blend of herbs that promotes spinal cord healing and therefore better “messaging” from his thoughts to his actions. Herbal compounds can take 2-6 weeks to see improvement, so we started those once he was comfortable.

Two weeks into his rehab, Cage didn’t have sore muscles but his elbows were very uncomfortable. Remember that he had severe arthritis in both elbows for a few years now. And with 4 weeks of him putting most of his weight on his front legs, the elbows were causing him a lot of discomfort. We focused therapy with TENS and therapy laser to the elbows for short-term relief.

I also started him on Adequan injections. This is a substance that has anti-inflammatory properties and also helps prevent the cartilage from wearing down. With intact cartilage, we avoid bone on bone contact which is extremely painful. The injections can have both short and long term positive effects on the joints. They are injected into the muscle so they help ALL of his joints (remember he had knee surgery and has arthritis there as well).

With these two mechanisms in place, we had a steady routine with Cage. Each day he got acupuncture, heat, massage, range of motion exercises, electrical stimulation and therapy laser treatments.

Each day we helped him to stand so that he could relieve himself (sometimes we had to stimulate him but he progressively was able to go on his own if we were patient with him). Each day he was with us he got to float in the underwater treadmill. Here the buoyancy of the water allowed him to feel like he weighed 45 pounds instead of 70.

Some days he showed progress. Some days he didn’t. What was important was that he didn’t show any regression. Neurological rehab takes time. Nerves heal at about a MILLIMETER per DAY. That means an inch of nerve can take up to 254 days to heal, that’s over 8 months. This is why it is important to be patient with these patients.

While we were doing things to promote better nerve conduction (acupuncture, TENS) and increased sensory input (having him standing, using his legs, letting him urinate on his own), we also worked on him having muscle to be there once the message came from the nerve. So, each day, he got electrical stim pads applied to his hind legs and spinal muscle groups. The goal here was to minimize the atrophy that was occurring. Electrical stim won’t replace the body’s natural muscle tone or strength but it can be used to contract muscle and can minimize atrophy. If we don’t do these things, then even if the message gets from his brain to his legs to move there isn’t any muscle to do the actual work.

Even with keeping up with food and trying to minimize atrophy, Cage dropped another 6 pounds in the first 4 weeks he was with us.

Initially, any physical activity was exhausting for Cage. Even with our support and the buoyancy of the water, he still had to move against gravity. With each week, he made noticeable progress. Some weeks were tougher than others because sometimes he was mentally checked out. We built in rest days for him to recover. Mostly these were at home with family. Occasionally, we asked him to do less physically when in our facility because of the time spent being active with his family.

For the first few weeks in the underwater treadmill, I would be in there with him moving his legs for him. As he got stronger, I would be in there just to act as a bumper and keep him from sliding back on the treadmill. He eventually got wise to this and stopped putting in effort. Then, I took myself out of the treadmill and we worked with him on a harness to keep him walking. Our results were mixed some days. He was not a food motivated or praise motivated dog. In talking with his family, they mentioned one particular toy he was fond of. I asked them to bring that to his next session. It was a tennis ball “dumbbell” with a built in squeaker. Here is a picture.

dumbbell

 

This really changed everything. Now comfortable and moving, Cage WANTED that toy. We could use this to motivate him to play tug-of-war or to get him to fetch it in the treadmill. This proverbial “carrot on a stick” is what clicked for him. Sometimes it’s really the simple things that make us happiest.

When Cage first arrived, he could barely walk and needed a break in the underwater treadmill after 5 minutes. A month into rehab and he could walk for 30 minutes at a time. The water’s buoyancy helped him greatly. On dry land, he was limited but walking. What we saw was progress, motivation and strength.

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Cage’s Rehab: Part One

Being a paralyzed dog is hard. Being that dog’s parents can be just as challenging. It’s scary, there are a lot of unknowns and it can get expensive quickly. I don’t deny any of these. From a patient’s perspective they can get frustrated very quickly. Imagine if 99% of what you did today you couldn’t do tomorrow.

Think how you would feel in the pet’s position: To be dependent on others to sit you up, feed you, clean you; To not have the independence to stand up and walk, or to simply sit up. This is why we my team and I look to achieve a comfortable and stable atmosphere for the patient through empathy. We are objective and analytical throughout our treatment, this guides us as we make small, incremental steps in the right direction or re-assess when and where progress slows and stalls.

I met Cage on July 1st, 2015. On my initial physical exam, aside form his neurological deficits and elbow arthritis he had muscle soreness of his shoulders, front legs, neck and back muscles. This is common in paralyzed dogs because they are using tremendous amounts of effort to get themselves up and drag their hind end.

After discussing options and prognosis with the owners, they elected to take him home that night and return the next day to begin rehab. After initial evaluations I break rehabilitation down into three segments:

1) Pain Management – Reducing the pain load on the patient

2) Strength Building – Working muscles to regain motor control and coordination

3) Maintenance – Sustaining gains after treatment

 

It is the third part that incorporates proper nutrition and regular exercise as ways to protect the body or minimize progression of diseases. A commitment is needed to maintain the hard earned gains from treatment. I also ask for a commitment to get through the first two phases, no matter how dark and dismal they may seem. My patients (and clients) require patience.

Cage had an excellent neurosurgical team in Boston. They worked hard to do mechanical aspects and provide multimodal pain management. Cage had taken meloxicam (an NSAID) for his arthritis for years along with amantadine to provide pain relief. After surgery, they added in gabapentin and tramadol to alleviate the post-surgical pain and the pain from his compressed disc and subsequent infection.

I started acupuncture on Cage the first day. Acupuncture helps to release the body’s natural endorphins (what morphine is made from essentially). This, in conjunction with TENS (transcutaneous electric nerve stimulation), would help alleviate the pain in his muscles. He also received daily treatments with our therapy laser. This would target sore muscles and help release cytokines to promote muscle healing and an anti-inflammatory action. After a few days, Cage was more comfortable. His muscles didn’t jerk and spasm in his neck and shoulders.

Each day he was with us, Cage received hot packs applied to his sore muscles to warm them up. Then he was stretched out, massaged gently and all of his joints were put through cycles of normal range of motion. When a body is not weight bearing muscles atrophy quickly. If normal pressure isn’t applied to our joints, they can become stiff from inactivity.

After being warmed up, Cage was placed in either the underwater treadmill or our overhead hoist. This allowed him to stand in a normal position and see the world. It also gave his body feedback (the joints, nerves and muscles all need gravity input to function normally). He would then have electrical stimulation applied to his rear legs to “teach” his muscles how to contract again. After that, he would rest lying down with ice packs on his muscles and joints. A week later, I was able to discontinue tramadol, one of the pain medications he was on.

Each day, we were expressing his bladder and bowels 3-4 times a day. We needed to teach those nerves and muscles to do their job just like the rest of his body. On July 10th, I noticed that his urine had a foul odor to it. A test showed that he had developed a urinary tract infection. These can occur in paralyzed dogs because they are not always emptying their bladder fully. We cultured it hoping that we could just increase the antibiotic he was on for the spinal cord infection, or at least get both infections with one antibiotic. This wasn’t the case as his particular infection was resistant to many drugs. We added in another oral antibiotic to his regiment and carried on.

After the first two weeks, Cage showed improvement. In the underwater treadmill he could pull his rear limbs forward. When suspended on the overhead hoist he could stand and pull himself forward. When I placed acupuncture needles at different points, I saw progress in how the messages were being conducted along his nerves.

During this time, he became very attached to me. He would follow me around the room with his eyes and would take his pills or eat for me when he wouldn’t do it for others. I was a little worried about this but was also glad to have him engaging and participating. After daily updates and then a reassessment after 3 weeks, I recommended we continue with rehab. His parents agreed. They saw he was more comfortable. Our goal now would be to make him stronger.

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